Mental health policy regarding members of the public I require please. I have today decided to disclose the located information to you in full.

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1 Freedom of Information Request Reference No: I note you seek access to the following information: Mental Health Policy Mental health policy regarding members of the public I require please. DECISION I have today decided to disclose the located information to you in full. Please note that the attached MPS Toolkit is based on current legislation, codes of practice and best practice, all of which are in the public domain. Please find attached information pursuant to your request. I would like to take this opportunity to thank you for your interest in the Metropolitan Police Service. Information Rights Unit

2 Freedom of Information Publication Scheme Protective Marking: Not Protectively Marked Publication (Y/N): Y Title: MPS Mental Health Toolkit 2017 Summary: Branch / OCU: MPS Mental Health Toolkit 2017: Operational and tactical guidance for Police Officers and staff when dealing with someone who has mental ill health TP C&S Date created: 26 th July 2017 Review date: July 2021 Version: 1.0 Author: TP C&S Central Mental Health Team Mental Health Toolkit 2017 Important Notice: The Policing and Crime Act 2017 amends police powers under Sections 135 and 136 of the Mental Health Act 1983 in respect of persons who are experiencing mental health problems, but have committed no crime. When Mental Health Act amendments become law changes will be made to the content of this MPS Mental Health Toolkit. Introduction This Toolkit is specifically geared towards providing clear operational and tactical guidance for Police Officers and staff when dealing with someone who has mental ill health. A number of new areas of guidance are offered in response to a range of emerging issues across London. This version also includes elements of the recently updated Mental Health Codes of Practice, the Pan- London s136 Pathway and information about the College of Policing s new Memorandum Of Understanding around police use of restraint in mental health settings. It may be circulated freely to external partners and may help Senior Leadership Team Officers and Borough Mental Health Liaison Officers explain the police position to the management and staff in local health trusts. Application These Mental Health Toolkits are effective from July The MPS Mental Health Team has produced this Toolkit which provides instructions, advice and guidance for officers, police staff and supervisors relating to mental health. However, these Toolkits apply in particular to officers and staff in the following roles: Borough Commanders Mental Health Liaison Officers Police officers and staff with responsibility for risk assessing and planning mental health assessments and the execution of Section 135(2) Mental Health Act 1983 warrants for patients absent without leave Police officers and staff responding to incidents involving a person with mental ill health N.B. This list is not intended to be exhaustive Metropolitan Police Mental Health Toolkit 1

3 Quick Reference Guide The principle statutes governing state responses to individuals experiencing mental ill health are the Mental Health Act 1983 (MHA 1983) and the Mental Capacity Act 2005 (MCA). Officers and staff should give additional consideration to the various codes of practice issued by the secretaries of state in England and Wales, as appropriate: Code of Practice (2015) to MHA 1983 for England Code of Practice (2005) to MCA (England and Wales) Code of Practice on (2008) MCA Deprivation of Liberty Safeguards (England and Wales). Section 2 MHA May be used by an Approved Mental Health Professional (AMHP) to allow a person thought to be suffering from a mental disorder (where it is in the interests of their own health or safety, or the protection of other people) to be admitted to hospital as a patient. Hospital admission may last for up to 28 days for assessment of their condition and any treatment as deemed necessary. Section 3 MHA People who require treatment for a mental disorder may be admitted to hospital under section 3 MHA Admission lasts initially for up to six months but can be renewed. Section 4 MHA Is an emergency admission provision that may only last 72 hours. When applying for admission under section 4, an AMHP (or nearest relative) requires one medical recommendation from a section 12-approved doctor. This provision may only be used in cases of urgent necessity where the wait for a second doctor would involve undue delay. Section 5 MHA Any doctor or any specialist nurse can detain a person who is already a hospital inpatient for a brief period of time, in order to allow for a MHA 1983 assessment. All doctors and some nurses have an authority under section 5 MHA 1983 to apply a holding power to hospital inpatients where they believe a patient is in need of assessment for detention under the Act. A doctor s authority (under section 5(2) MHA 1983) allows detention for up to 72 hours. A nurse of the prescribed class, which usually means a mental health, learning disabilities or child/adolescent mental health nurse, may hold a patient for up to six hours (under section 5(4) MHA 1983). These powers cannot be used in hospital emergency departments (ED) because the powers relate only to inpatients. Where officers are called to inpatient hospital wards and asked to consider implementing section 136 MHA 1983, they should bear in mind paragraph of the MHA 1983 Code of Practice. This requires nurses and doctors to consider holding powers for inpatients, ahead of calling the police to a situation of inpatient care. Metropolitan Police Mental Health Toolkit 2

4 Section 6 MHA Once an AMHP has made an application for a person s admission as an inpatient under any of the above provisions, section 6 MHA 1983 provides authority for them to detain and convey the patient to hospital. The patient is liable to be detained when the application is completed by the AMHP and that person is then, by virtue of section 137 MHA 1983, in the AMHP s legal custody (sectioned). Reasonable force may be used (by the AMHP) to detain and convey the patient as necessary and proportionate. The AMHP may delegate their authority under section 6 to others. This would typically be to a police officer and/or paramedic who would then also have the right to use reasonable force to detain and convey the patient to hospital. Nothing obliges another person to accept the AMHP s delegated authority under section 6. Once authority has been delegated to another person (a police officer or paramedic), decisions about conveyance and the use of restraint lie with the person with delegated authority. Section 18 MHA Section 18 provides a power for any patient absent without leave to be re-detained and returned to the hospital by: an AMHP anyone on the staff of the hospital a constable anyone authorised (in writing) by hospital managers Entry cannot be forced to a premises for this purpose and a warrant under section 135(2) MHA 1983 would be required if consent to enter the premises is not provided. Section 18(1) states that a patient becomes AWOL if they: absent themself from the hospital without leave granted under section 17 MHA 1983 fail to return to the hospital at the expiration of any period of leave or on being recalled from leave absent themself without permission from any place where they are required to reside in accordance with conditions imposed on any grant of leave. Section 18 MHA 1983 is a power of arrest for the purposes of the Police and Criminal Evidence Act 1984 (PACE) and therefore reasonable force may be used under section 117 PACE 1984 where necessary and proportionate. MHA 1983 detainees may be searched under section 32 PACE 1984 where sufficient grounds are met. Section 35, 36 and 38 Re-detention of patients subject to hospital orders Section 35 allows for patients who have been charged with a criminal offence to be remanded to hospital for treatment and psychiatric reports. Section 36 allows for patients who have been charged with a criminal offence to be remanded to hospital for treatment pending trial. Metropolitan Police Mental Health Toolkit 3

5 Section 38 allows courts to impose an interim hospital order following conviction in court. This allows clinicians to form a view as to whether a full hospital order under section 37 would be an appropriate disposal for a defendant. Where a person absconds under any of these three forensic sections, there are particular powers of re-detention which differ from other AWOL patients. Section 35(10), section 36(8) and section 38(7) allow patients detained under these sections to be re-detained by police officers, who then have a duty to return the person to the court in which the relevant order to detain them in hospital was granted. Section 18 MHA 1983 does not apply to those patients detained under sections 35, 36 or 38 and a warrant under section 135(2) would still be required to force entry to any premises, unless officers have grounds to enter under section 17 Police and Criminal Evidence Act (PACE) or common law. Section 37 MHA After conviction in the criminal courts, the court may by order authorise admission to, and detention in, a specified hospital. The court may also place the subject under the guardianship of a local social services authority or another person approved by a local social services authority. Section 41 MHA The crown court can impose a restriction order under section 41 MHA Patients subject to a restriction order are known as restricted patients. The restrictions set out in this section can be applied to the following patients: Section 37 (hospital order) patients only the crown court can impose a restriction order for these patients. In deciding whether to impose a restriction order, the judge will consider the nature of the offence, the offender s criminal record and the risk of further offences being committed if they are released (see section 41(1)). Section 47 prison transfer patients (the restrictions are imposed via section 49) in this case the restrictions (on a determinate sentence only) end on the prisoner s non-parole date. The Ministry of Justice almost always imposes the restrictions, unless the patient is near the end of their sentence (and therefore would soon cease to be subject to the conditions anyway). Section 45A hospital direction patients in these cases the restrictions are always imposed via a limitation direction. Patients sectioned under the Criminal Procedure (Insanity & Unfitness to Plead) Act Section 42 MHA Allows a patient who has been or is subject to a criminal justice process, who has been detained on a restricted hospital order (section 37/41 MHA 1983), to be conditionally discharged to receive community care, sometimes with conditions and restrictions attached. During this period of conditional discharge, patients are liable to be recalled to hospital by the secretary of state who may issue a warrant under section 42(3) MHA 1983 ordering the recall. A warrant under this section is not a warrant of arrest for the purposes of section 17 PACE. It will be usual for the police to be involved in this process, however, given that conditionally discharged patients were, by definition, thought previously to have posed a risk of serious harm to the public. Metropolitan Police Mental Health Toolkit 4

6 Where entry needs to be forced in connection with this recall, a warrant under section 135(2) MHA 1983 is required unless grounds exist under PACE. Section 135(1) MHA Relates to entering premises to search for people who are to be assessed under MHA 1983 for potential admission to hospital. Warrants may be issued by a magistrate under section 135(1) following an application by an AMHP where there are reasonable grounds to suspect that a person thought to have a mental disorder is being or has been ill-treated, neglected or kept otherwise than under proper control, or, if living alone, is unable to care for themself. Section 135(1) then allows a constable (who must be accompanied by an AMHP and a doctor) to enter the premises specified, if need be by force (section 135(4)), in order to search for the individual named in the warrant. The warrant further authorises the officer to remove that person to a place of safety, for consideration of whether to make an application for their admission to hospital under MHA The warrant authorises two legal powers for police officers: entry to the premises, if need be by force removal of the person concerned to a place of safety. Section 135(2) MHA Allows a warrant to be issued by a magistrate on application by an AMHP, a constable or anyone authorised by hospital managers, in order to re-detain someone who is liable to be detained or already absent without leave (as defined in section 17 MHA 1983). The person applying for the warrant should be the professional with the most relevant and accurate information in that case. Although there is no legal necessity for a AMHP and/or doctor to be present when a section 135(2) warrant is executed, section 135(4) states that an officer may be accompanied by a doctor or anyone authorised under MHA 1983 to re-detain a patient. Section 136 MHA If a constable finds a person who appears to be suffering from a mental disorder in a place to which the public has access, and that person is in immediate need of care or control, the officer can, in their best interests or for the protection of others, remove that person to a place of safety. Section 138 MHA Provides the police with a power to detain or recover someone who has absented themselves from lawful custody in one of two situations: recover someone who absconded from section 135(1) or section 136 and return them to a place of safety (this power lasts for 72 hours after they went AWOL or after arrival at the place of safety, whichever is sooner) detain someone who absconded after being sectioned but before being admitted to hospital (this is known as someone who is liable to be detained ). MENTAL CAPACITY ACT Metropolitan Police Mental Health Toolkit 5

7 Section 1 The following five principles should govern police responses when applying the MCA: 1. officers must assume that a person has capacity unless it is established that they lack capacity 2. officers should not treat a person as unable to make a decision unless they have taken all practicable steps to help the person to do so without success 3. officers should not treat a person as unable to make a decision merely because they make an unwise decision 4. officers should act or make decisions under this Act for or on behalf of a person who lacks capacity in that person s best interests 5. before acting or making the decision, officers must have regard to whether they can achieve the purpose for which it is needed as effectively in a way that is less restrictive of the person s rights and freedom of action. Section 2 For the purpose of this Act a person (aged 16 or older) lacks capacity in relation to a matter if, at the material time, they are unable to make a decision for themselves in relation to the matter because of an impairment or disturbance in the functioning of the mind or brain. It does not matter whether the impairment or disturbance is permanent or temporary. A lack of capacity cannot be established merely by reference to: a person s age or appearance a condition or an aspect of their behaviour, which might lead others to make unjustified assumptions about their capacity. Any question about whether a person lacks capacity within the meaning of this Act must be decided on the balance of probabilities. Section 4 Removing a person who lacks the mental capacity to take the decision in question for themselves will usually amount to a deprivation of liberty (section 4B MCA) and may only occur where it is necessary to provide a life-sustaining treatment or to do a vital act necessary to prevent a serious deterioration in their health. Section 5 and section 6 MCA do not confer on police officers any authority to remove people to hospital or other places of safety for the purposes of mental health assessment. Metropolitan Police Mental Health Toolkit 6

8 Contents 1. Risks associated with prolonged violent restraint Safety and confidence the MPS role in local partnerships Responsibilities of Borough Commanders Key areas of responsibility for SLT Leads 4. Mental illness in public places S136 Mental Health Act Definition of S136(1) Mental Health Act A Place to which the public have access.. Deciding to use S136(1) Mental Health Act Effects of detaining someone under S136(1) MHA. Police action following detention under S136(1) MHA Police Stations as a Place of Safety.. Police Officers being delayed at Places of Safety and other practical problems... The role of an Emergency Department (ED) in a S136 pathway.. Parallel assessments in the Emergency Department. S136 MHA and transfers between Places of Safety Using S136 in circumstances where a power of arrest for other matters are available S136 MHA and private premises... S136 MHA and the Mental Capacity Act 2005 Form 434 and recording S136 onto Merlin database. Responsibilities of SLT and BMHLO 5. Mental illness in private premises S135(1) Mental Health Act Dealing with pre-planned Mental Health Act assessments on private premises.. Responding to requests for police involvement when conducting Mental Health Act assessments. Why do the police attend Mental Health assessments. The benefits of a warrant obtained under S135(1) Mental Health Act Police attendance is requested to manage risks... Police attendance to promote cooperation. Police lead at Mental Health Act assessments... Planning for police attendance at Mental Health assessments without a warrant.. Producing the warrant at the point of entry The relationship between warrants and consent to entry Entry to premises in cases where one occupant consents. Hostels and Hotel Rooms.. Situations where consent is expected. Cases where the court refuses to issue a warrant Guidance to help AMHPs apply for a S135(1) MHA warrant.. Dealing with a spontaneous mental health incident on private premises.. Entry powers and Restraint powers in these circumstances Responsibilities of SLT and BMHLO Metropolitan Police Mental Health Toolkit 7

9 6. Patient recalls and AWOLS Police Powers and Responsibilities. 34 Healthcare responsibilities.. Responsibility for detaining and returning hospital patients. Conditionally discharged restricted patients recalled by warrant. Convicted offenders detained in psychiatric hospitals notification to police Powers of entry in order to detain using a warrant S135(2) Mental Health Act 1983 Police involvement in detaining and returning someone who is absent without leave. Risk Assessment and executing S135(2) MHA warrants.. Patients absconding from hospital whilst involved in criminal proceedings Responsibilities of SLT and BMHLO. 7. Powers to search detained patients in psychiatric hospitals Transporting of dangerous or violent patients who present a high risk. 40 Police role and use of police vehicles. Requests from Health Trusts for police to transfer patients between hospitals... Transfers of dangerous or violent patients who present a high risk.. Instructions for Duty Officers authorising escorts of dangerous or violent patients Transportation of AWOL patients detained by police a long distance from hospital from which missing Responsibilities of SLT and BMHLO.. 9. S37/41 Mental Health Act 1983 When police get involved 46 Practical scenario s and police actions.. Finding a missing patient who is subject to S37/41 Mental Health Act Patient subject to S37/41 MHA and arrested for a criminal offence. Decision to prosecute for Escape from Lawful Custody for those subject to S37/41 MHA. S136 Mental Health Act 1983 and S37/41 MHA Hospital/Restriction Order Transport arrangements for patients from outside the police area... S37 MHA Hospital Order and not S41 MHA Restriction Order.. Additional mention; Police involvement in situations involving S47/49 or S48/49 MHA 10. Community Treatment Orders (CTO) and Guardianship. 49 Community Treatment Order Police involvement in urgent cases of a CTO recall. Consideration of a S135(2) MHA warrant for circumstances involving private premises.. Guardianship.. Reporting a patient missing who is subject to Guardianship. Finding a missing patient who is subject to Guardianship. Patients safe return to Guardian when found in different area. 11. Mental Capacity Act 2005 Appropriate use by Police Officers 52 Applying the Act to practical policing situations Step 1 Determining someone s Mental Capacity.. Step 2 Determining what is in someone s best interests. Step 3 Consider using restraint Step 4 Record your decisions and actions. Inappropriate reliance upon the Mental Capacity Act 2005 Practical examples Use of the Mental Capacity Act at Mental Health assessments Less life-threatening situation Responsibilities of BMHLO.. Metropolitan Police Mental Health Toolkit 8

10 12. Mental illness within MPS Custody Centres.. 59 Liaison and Diversion. Dual arrests using S136 MHA and other matters Appropriate Adults for those with mental health issues.. Mental Health Act assessments and bed availability issues whilst in custody... Legalities of keeping someone detained whilst waiting for a bed. How Custody Officers/Staff escalate such cases High Risk Detainees. Mental Capacity Act 2005 and restraint in custody. Dealing with practical problems in the Custody Centre.. Responsibilities of SLT and BMHLO Responding to offences where a suspect is mentally ill 66 Use of specific Police Investigating Officer placed within the Mental Health Hospital Responsibilities of SLT and BMHLO Emergencies involving violent patients in a Psychiatric Hospital Examples requiring a police response The MPS over-arching ethos to responding to violent patients within Mental Health settings... Police powers of restraint in Mental Health settings. Mental Health Act Other Legal provisions Mental Health implications re case of Hicks v MPS Commissioner Breach of the peace example in mental health scenario. Protocol that Police Officers should follow in response to attending a call Considering Arrest for a criminal offence Administration... Summary The offence of causing a nuisance or disturbance in NHS premises.. Responsibilities of SLT and BMHLO. 15. Restraining patients to administer rapid tranquilisation 74 MPS position. Administering medicines. Tactical Options Responsibilities of SLT and BMHLO. 16. Welfare Checks.. 76 Overlap with S17 PACE & Human Rights Act 1988 Escalation... Responsibilities of SLT and BMHLO.. End note references used throughout Mental Health Toolkit 80 Metropolitan Police Mental Health Toolkit 9

11 (1) MHA Risks associated with prolonged violent restraint 1.1 There will be occasions where it may be necessary to restrain an individual with a mental illness. Where the person resists the restraint in a violent, prolonged manner the physical stress on the person s body may result in death or serious injury. Where a person has been restrained in a violent, prolonged manner the police officer(s) concerned must treat the situation as a medical emergency and obtain emergency medical care for them, by summoning an ambulance to take the person to an Emergency Department. 1.2 Officers MUST be aware that Mental Health + ongoing physical restraint = medical emergency. The London Ambulance Service (LAS) will respond to such a request as a priority. 1.3 Officers MUST use clear language to obtain the correct response from LAS (E.g. that the person is detained under S136 Mental Health Act and is suffering from Acute Behavioural Disorder (ABD)). 1.4 Where the person is violent, transportation by police vehicle is permitted in accordance with the agreement between the LAS and the MPS facilitating the transportation of people to hospital. Link to MPS/LAS agreed MOU The provision of such emergency medical care must take priority over the provision of mental health care. Likewise, if there is any suspicion that the person is otherwise physically ill or injured then medical care must be sought immediately Safety & Confidence the MPS role in local partnerships 2.1 The Mental Health Act 1983, the Mental Capacity Act 2005 and their associated codes of practice provide the MPS with a clear framework in which to operate when delivering a service 0 Metropolitan Police Mental Health Toolkit 1

12 involving someone with a mental illness or who lacks capacity. In order to achieve the two priorities of safety and confidence it is essential that operational officers and senior leadership teams have a clear understanding of the police role within local partnerships. Senior Management Teams, Borough Mental Health Liaison Officers and operational staff must have the confidence to articulate this understanding to colleagues in local mental health trusts. 2.2 Virtually all MPS activity in the field of mental ill health involves working with staff in health and social care. This guidance sets out within a number of areas what roles the MPS should perform and how. The MPS priorities of safety and confidence will best be achieved by: Police officers fully understanding and carrying out areas of activity for which police are properly responsible MPS borough senior leadership teams and mental health liaison officers ensuring their partners understand the Police role. This is specifically relevant where Police are improperly requested to carry out functions that place the mentally ill person at increased risk, create vulnerabilities for the MPS or reduce the capacity of response team officers by diverting Police resources into areas of business for which other partners are responsible. 3. Responsibilities of Borough Commanders 3.1 Borough Commanders are responsible for ensuring that a Police Officer is assigned to build and maintain relationships with partners in relation to all aspects of operational policing involving someone with a mental illness - Borough Mental Health Liaison Officer (BMHLO). This will include resolving disputes between police and partners. 3.2 Borough Commanders must also nominate a member of their Senior Leadership Team to take overall responsibility for both the general delivery of operational policing and the following specific functions: Consultation with the Chief Executive/Chief Operating Officer of the mental health trust or equivalent to ensure that specific local arrangements are in place in relation to high risk areas of business. These arrangements are clearly shown under SLT Responsibilities, throughout this Toolkit and the relevant areas are summarised below. Ensuring that mental health and policing form part of the strategic assessment Ensuring that all Police Officers on the borough are aware of these Toolkits 3.3 Key areas of responsibility for SLT leads: 1. Mental illness in public places Section 136 Mental Health Act Mental illness in private premises, Section 135(1) Mental Health Act Transporting detained patients including violent and dangerous patients 4. Responding to requests to restrain patients within health environments 5. Responding to requests for police to conduct a Welfare Check 1 Metropolitan Police Mental Health Toolkit 1

13 4. Mental illness in public places S136 MHA 1983 Definition of Section 136(1) 4.1 If a constable finds in a place to which the public have access a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons, remove that person to a place of safety within the meaning of Section 135. A place to which the public have access 4.2 This is not defined under the Mental Health Act, and has the same meaning as in any other legislation: a place to which the public have lawful access whether on payment or otherwise; this includes an Emergency Department of a hospital, and places to which members of the public have access at certain times of day, e.g. a public house. It does not include private premises such as a front garden 1. It is not appropriate to encourage a person outside in order to use Section 136 powers. See MHT Bulletin 4 re Police actions when someone leaves their private address Deciding to use Section 136(1) 4.3 When deciding that detention may be necessary, a police officer may benefit from seeking advice before using Section 136 powers in cases where they are unsure that the circumstances are sufficiently serious for using these powers. Local protocols should set out how this advice can be provided and who the police should contact, including outside of normal business hours. Currently in London many Mental Health Trusts are in the process of introducing Single Points of Access (SPA s) or Mental Health Triage services, which are available to the Metropolitan Police. 4.4 When considering the use of police powers to detain people under the Act, less restrictive alternatives to detention should be considered. Health and/or social care professionals may be able to identify alternative options. For example, with the person s consent, the police, or any other qualified person may convene a mental health assessment without using Section 135 or Section 136 powers, by requesting that a Section 12 approved doctor attend in order to assess the person and make any arrangements for their on-going care. Where appropriate, and depending on specific circumstances, consultation with carers may help, particularly in the case of children and young people. 4.5 A police officer may use Section 136 if they encounter the person (of any age) in a place to which the public have access, including if they are already on scene, responding to a call, are approached, or otherwise come into contact with the person. Either finding or being directed towards a person with mental disorder in a public place is not enough in itself to detain under Section 136. The power to remove requires 3 conditions to be fulfilled before police act. The person must appear to the officer to be suffering from mental disorder They must appear to the officer to be in immediate need of care or control The officer must think that it is necessary to remove the person in their own interests or for the protection of others 2 Metropolitan Police Mental Health Toolkit 1

14 4.6 The clear implication is that the officer must believe the person or someone else will suffer some kind of harm if they do not take action to remove them. Simply behaving in an odd or unusual way does not necessarily mean they should be removed. The power to remove under Section 136 does not expect police officers to make diagnoses of someone s mental state but provides power to officers who believe in good faith that someone is mentally ill and requires immediate care and control to remove them to a place of safety. 4.7 Local policies should ensure that police officers know who to contact prior to the removal of a person to a place of safety under Section 136, in order to help secure their acceptance into a health-based place of safety. On each occasion when the S136 power is used, the police officer involved is expected to phone ahead to the nearest agreed Health Based Place of Safety to inform them of the individual s imminent arrival and to confirm that the site is able to receive them. If the Health Based Place of Safety is notified in advance but does not have the capacity to receive the person, the S136 coordinator at the site should advise of an alternative Place of Safety and/or escalate the matter as required. However, failure by the police officer to ring ahead may result in the person being unable to be accepted upon arrival, resulting in avoidable delay. 4.8 When responding to incidents involving children who are experiencing mental health problems or distress, the overriding consideration should always be the welfare of the child, ensuring protection from harm and access to assessment where appropriate. Children of any age may be detained using section 136 MHA 1983, and any person under 18 years of age may be taken into police protection using section 46 of the Children Act Where officers have the option to use both statutes, a police protection order (PPO) under the Children Act 1989 may be used, as this is more likely to ensure that the child is not unnecessarily institutionalised or stigmatised by the process. A PPO provides additional flexibility and does not require a police officer to make judgement as to whether a child is likely to be suffering from a mental disorder and in need of care and control. A PPO may be used if a police officer has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. There is no restriction on using a PPO in a home or place to which the public do not have access, so police officers may use a PPO to move a disturbed child who is at home, in the interests of their health and safety. The maximum duration of detention under a PPO is 72 hours (the same as section 136 MHA 1983). During this time, officers are able to request that the child has access to all necessary assessments (including, if required, an assessment for detention under section 2 or section 3 MHA 1983, or a social care assessment). 4.9 Effects of detaining someone under Section 136 The person is considered to be under arrest and can be searched under Section 32 of the Police and Criminal Evidence Act 1984 The person can be detained at the place of safety for up to 72 hours for the purpose of enabling him to be examined by a registered medical practitioner and to be interviewed by an Approved Mental Health Professional (AMHP) and of making any necessary arrangements for his treatment / care From the time the person is detained until the time the examination and assessment are complete the person is deemed to be in lawful custody and where the place of safety is a 3 Metropolitan Police Mental Health Toolkit 1

15 hospital or other health facility can be detained at the place of safety by police and members of hospital staff 2 The person is entitled to legal advice, regardless of which place of safety they are taken to and additionally entitled on request to have one person known to them or likely to take an interest in their welfare informed of their whereabouts Whilst Section 136 does not use the term arrest, it is a preserved power of arrest under Section 26 PACE and reasonable force may be used under Section 117 PACE. Section 28 PACE requires an arrested person to be told that they are under arrest and the grounds for the arrest. Whilst a person detained under Section 136 is entitled to know that their liberty is being temporarily restricted, formally telling them that they are under arrest may be counter-productive Therefore, the word arrest should be avoided, and instead the police officer should use tact and discretion in communicating to the person that they will have to come with police because of the officer s concern for their well being, and that they have no choice in the matter. There is no requirement to caution a person detained under S136 and this should not be done. Police Action following detention under Section Once a person has been detained the Mental Health Act 1983 code of practice requires that the officer detaining is responsible for notifying the place of safety in advance of their arrival and for notifying the Local Social Services Authority. However, if officers take the person detained under S136 Mental Health Act to a Health Based Place of Safety, NHS London (as referenced in para 1.7 of London s S136 Care Pathway document 3 ) states that it is the responsibility of the staff at the Health Based Place of Safety for informing the duty Approved Mental Health Professional (AMHP) and duty s12 doctor as soon as they have received the individual. Information on the transportation of patients detained under the Mental Health Act can be found in Section 8 of this Toolkit 4.13 Whilst exceptions apply for example no ambulance being available, as a general rule the person must be taken to the place of safety by ambulance in accordance with the agreement between the MPS and LAS, unless they are so violent or dangerous that it is necessary to use a police vehicle. Where a police vehicle is used a paramedic should accompany the patient with the ambulance following. The person should be taken to the locally agreed place of safety for the borough where they are detained The Ambulance service or other service transporting the individual will always go to the Health Based Place of Safety closest to where the individual was detained. However crisis care plans which may include a preferred place of assessment should always be taken into account where feasible Where the place of safety is not located at an Emergency Department, and the person detained is suffering from a physical condition (e.g. injury or apparent illness such as a heart condition) then they should be taken to the Emergency Department for their physical condition to be treated. The LAS crew will make this decision. Upon arrival at the Emergency Department, the police officers involved should make it clear to ED staff that the person is detained under S Metropolitan Police Mental Health Toolkit 1

16 After physical examination, consideration may then be given to transferring them to the local mental health based place of safety. See below London s S136 Pathway and Health Based Place of Safety specification - section 2.12 Ref Specification Responsibility 2.12 If the s136 coordinator and Health Based Place of Safety team feel unable to meet the physical needs of the individual and they need to go to the A&E department, staff at the Health Based Place of Safety has the right of refusal to the site. However concerns should always be escalated to an on call doctor e.g. on call Higher Specialty Trainee (SpR), Core Trainee (SHO) or Associate Specialist. The on call Consultant could be approached for mediation or consultation if an agreement has not been reached but the final clinical decision as to whether the individual requires medical assistance at the A&E department lies with the doctor at the Health Based Place of Safety. Conversations will involve discussions regarding the specific concerns of staff and what additional assessment or intervention is required. Health Based Place of Safety 4.16 If the individual is taken to an Emergency Department (ED) first under section 136, the 24 hour detention period commences on arrival at ED, not when they subsequently arrive at the Health Based Place of Safety. When the individual arrives it is important that the status of the individual (whether they are detained under s136 or not) is communicated to ED staff straight away. Police Stations as a place of safety 4.17 It is MPS policy and a requirement of the MHA code of practice that a police station should only be used on an exceptional basis. S135(6) Mental Health Act 1983, defines a Place of Safety as; a residential accommodation provided by a local social services authority under Part III of the National Assistance Act 1948, a hospital as defined by this Act, a police station, an independent hospital or care home for mentally disordered person or any other suitable place the occupier of which is willing temporarily to receive the patient. In 2015 an ambition was set by London s Mental Health Partnership Board that a person detained under S136 Mental Health Act, should never end up in a police cell in London. 4 All agencies should work to bring the mentally ill person to the most appropriate place where appropriate care can be provided as soon as possible. The College of Policing states: Police custody must not be used because of a lack of space/beds and should only ever be used in exceptional circumstances If Police Officers are unable to gain access to a Mental Health based Place of Safety for whatever reason, before relying on a police station, they should comply with MHT Bulletin 5 and attend the nearest Emergency Department. Link to MHT Bulletin 5. This position is now endorsed 5 Metropolitan Police Mental Health Toolkit 1

17 by NHS London s section 136 pathway and Health Based Place of Safety Specification document, which was launched by the Mayor of London on 12 th December London's S136 pathway and Health Based PoS specification On page 24 it states, Under exceptional circumstances when an individual under S136 presents to an A&E/ED department with no physical health needs (due to limited Health Based Place of Safety capacity) the A&E/ED cannot refuse access unless a formal escalation action has been enacted On the very rare occasions where a police station is used, the MHA code places two clear responsibilities upon health and social care agencies. 1. They should work with the police to arrange transfer to a more suitable place of safety 2. They should work to locally agreed target times to either transfer the person or attend the police station and start assessment 5 Police officers being delayed at places of safety and other practical problems (including alcohol and drugs) 4.20 Local policies should cover arrangements for police officers to remain in attendance when a person arrives at a mental health-based place of safety. Healthcare staff, including ambulance staff, should take responsibility for the person as soon as possible, including preventing the person from absconding before the assessment can be carried out. The police officer should not be expected to remain until the assessment is completed; the officer should be able to leave when the situation is agreed to be safe for the patient and healthcare staff. Frequent disputes can arise between the staff at mental health based places of safety and the police about how long police should remain with the detainee or who has the legal power or responsibility to continue detaining the person whilst awaiting and then carrying out the assessment. If in complex cases it is proving difficult to reach consensus, senior management from the provider Trust and the police should liaise to resolve the situation Disputes also arise in relation to refusals to accept a person at the mental health based place of safety on the grounds they are full, the person is too violent or is under the influence of alcohol or drugs and cannot be assessed until in a fit condition. Intoxication (whether through drugs or alcohol) should not be used as a basis for exclusion from mental health places of safety, except in circumstances set out in the local policy. Mental health-based places of safety should not be conducting tests to determine intoxication as a reason for exclusion 6 ; this should be based on clinical judgement. It is the clinical decision of the suitably qualified doctor at the mental health based place of safety to make the decision as to whether the individual requires medical assistance at an Emergency Department. The locally agreed protocol for Section 136 involving police, health trust and other partners should set out how problems/disputes concerning access issues are resolved locally. For further information see London's S136 pathway and Health Based PoS specification (sections 2.25 to 2.28) 6 Metropolitan Police Mental Health Toolkit 1

18 4.22 The Association of Chief Police Officers and the Independent Police Complaints Commission (2012) describes drunk and incapable as an individual that has consumed alcohol to the point of being unable to either walk unaided or stand unaided or is unaware of their own actions or unable to fully understand what is said to them. Clinically where an individual meets the criteria for being drunk and incapable there is potential for airway compromise and the individual may be in need of urgent medical attention. If someone appears to be drunk and showing any 'aspect' of incapability which is perceived to result from that drunkenness, then that person must be treated as drunk and incapable. A person found to be drunk and incapable by the police should be treated as being in need of medical assistance and conveyed by ambulance to an Emergency Department. The same should occur for those who appear intoxicated by drugs to the point of being incapable If there is no capacity at the local Health Based Place of Safety when the police officer makes initial contact it is that site s responsibility 7 to resolve and use escalation protocols or find alternative arrangements, whether the individual is from that area or not. Such occurrences must be fully documented. However, the Health Based Place of Safety has no legal power to transfer the individual of their own volition, this needs to be done by or on behalf of a police officer or AMHP (see S136(3)). If no resolution can be found and police officers are struggling to find a suitable mental health based place of safety, they should follow MHT Bulletin 5 and take to the nearest Emergency Department. An ED is a very different environment to a purpose built mental health based place of safety, so police officers may have to remain with the person detained. MHT Bulletin 5 provides additional guidance. Under exceptional circumstances when an individual under s136 presents to an A&E department with no physical health needs (due to limited Health Based Place of Safety capacity) the A&E cannot refuse access unless a formal escalation action has been enacted as per the NHS England (London) A&E Capacity, Redirect and Closure Protocol. The role of an Emergency Department (ED) in a S136 pathway 4.24 An Emergency Department can itself be a Place of Safety within the meaning of the Mental Health Act. Therefore, if protracted physical health treatment or care is required, where appropriate the Acute Trust should choose to accept the Section 136 papers and take responsibility for the individual for the purposes of the Mental Health Act assessment being carried out. In these circumstances the individual continues to be detained under S136 until formally discharged by a s12 doctor and/or AMHP In these instances it is vital that information about the individual s needs, and any associated risks, are clearly explained to ED staff receiving the person and also documented in the S136 paperwork. Any security staff at the ED must likewise be properly briefed about the person before the ED takes responsibility for them. Due to the nature of ED s, managing individuals detained under Section 136 in this environment can be challenging. Given this, when an individual detained under S136 is in the ED police officers will provide the necessary support needed unless there is mutual agreement between the Department and the police officers that they are able to leave If the decision is taken that it is in the individual s best interest to transfer them from the ED to a mental health based place of safety for the purpose of the Mental Health Act Assessment, it must 7 Metropolitan Police Mental Health Toolkit 1

19 first be confirmed that the place of safety has capacity and is willing to receive the individual before the transfer takes place. It is the police s responsibility with the support of ED staff/s136 coordinator to secure this confirmation Whilst the individual is in the ED, London s S136 Care Pathway document makes reference 8 to how ED staff and mental health services must respond in a timely way to support appropriate assessment. These include: Liaison psychiatry services seeing the individual within 1 hour of receiving a referral from the ED; The AMHP and the s12 doctor attending within 3 hours wherever practicable for the purposes of undertaking a Mental Health Act assessment and; Completion of the Mental Health Act assessment by the AMHP and s12 doctor within 4 hours of the individual s presentation to ED. Parallel assessments in the Emergency Department 4.28 A Mental Health Act assessment should not be delayed for delivery of physical health treatment that has no predictable significant impact upon mental state. A MHA assessment should not however take place if there is suspicion that a physical condition is leading to or significantly worsening a disturbance of mind. On initial presentation in ED consideration should be given immediately to the appropriate assessment of both physical and mental health needs If an individual has been assessed in an ED and requires admission as an inpatient for further physical health care treatment at the Acute Trust, the patient will continue to be detained under Section 136 unless one of the following take place: The s12 doctor (or other doctor with mental health training and expertise) finds the person to have no underlying mental disorder, in which case they can discharge the individual from the S136 without input from the AMHP; A Mental Health Act assessment has been undertaken by a s12 doctor and AMHP and any necessary arrangements for the person s mental health care have been made, at which point the AMHP should formally discharge the S136; The detention period under S136 has elapsed, however it is not good practice to let this happen In these circumstances the Acute Trust should take responsibility for the person s custody; there should be a mutual agreement between ED and the police officers about when the officers are able to leave, taking into consideration the risk presented by that individual and police capacity to provide support While the detained individual is in the ED and is being treated for their physical health, the ED staff have a clinical duty of care to that individual with support from medical and psychiatry specialities. This duty of care continues until the individual leaves the ED The clinical duty of care for the individual outlined above should not be confused with overall legal responsibility. During the time in ED, the overall legal responsibility for the individual remains with the police, unless ED staff formally accept responsibility for the 8 Metropolitan Police Mental Health Toolkit 1